Trachs, Vents, And Passy-muir

Trachs, Vents, and Passy-Muir Valves Charles Williams, RRT Hillary Beck, SLP

Types of Tubes (Most commonly seen here) • • • •

Cuffed Shiley Uncuffed Shiley Fenesrated Trachs Fome Trach – Cuff inflates with negative pressure – Cuff cannot be deflated – Contraindication for PMV

Tube Parts • • • • • •

Outer Cannula Inner Cannula (disposable and non) Cuff (cuffed trachs only) Pilot Balloon (cuffed trachs only) Flange: Size and type found here Obturator (At bedside in case of need to reinsert the trach) • Cap (AKA Button, plug, cork) • Trach ties

Tube Sizes • Dependent on size of patient, vent/support needs and surgeon’s selection • Hard to ventilate patients will have larger tubes and size will be decreased with weaning away from the tube • Smaller people may have smaller tracheas and vice versa • Average size is a 6 • #8 or larger may contraindicate PMV placement due to limited space around the tube through which to move air into the upper airway

Fenestrated Tubes • Primarily for patients without respiratory failure • A fenestration is a hole in the outer cannula of the tube • The fenestration allows air to go into the trach that will be directed up through the vocal cords

Cuffed versus Uncuffed Trachs Note: Patients can sometimes voice around their trachs (if cuffless or if the cuffed trach tube is deflated).

• Seals trachea off from vocal cords, mouth, and nose • Allows delivery of support without resistance • Mostly seen in vent dependent patients

• Allows airflow through vocal cords, mouth, and nose • Mostly seen once patients are weaned off the vent and beginning the downsizing process • Used for sleep apnea, trauma patients, etc (Patients without respiratory failure)

Trach Cuffs • A syringe is used to inflate and deflate the cuff via the pilot balloon. • A cuff is fully deflated when the pilot balloon is flat and no more air comes out into the syringe • A cuff should be re-inflated using minimal leak technique (by trained clinicians only), when no more air can be heard in the upper airway. This can also be done using a manometer. • Over-inflation of a cuff can cause tracheal trauma and/or stenosis

Mechanical Ventilation Indications: • Apnea or impending respiratory failure (ARDS, CHF, Status Asthmaticus, Neuromuscular disease)

• Acute Respiratory Failure: – Hypoxemic respiratory failure (Type I failure) – Hypercapnic respiratory failure (Type II failure)

• Prophylactic Support: (Post-op, Post MI, Brain injury, etc.)

• Hyperventilation Therapy (Acute head injury)

Mechanical Ventilation Minimum required settings: – Mode (Pressure Control, SIMV, etc.) – Respiratory rate (# breaths per minute) – Tidal Volume (volume delivered per breath in ml’s) – FIO2 (inspired oxygen percentage) Additional settings: Pressure Support, PEEP

Mechanical Ventilation – Considerations Pressure mode vs. Volume mode Control mode vs. Support mode

Modes of Ventilation Spontaneous breathing

– Sinusoidal waveform – No ventilator support

Modes of Ventilation CPAP/PEEP CPAP

Positive End Expiratory Pressure

Continuous Positive Airway Pressure

5

PEEP

5

– Applied during spontaneous breathing – Used to treat OSA

– Applied during ventilator breaths

Improves oxygenation by “holding” the alveoli open.

Modes of Ventilation Pressure Support/CPAP

5

– Adds a set amount of pressure to spontaneous breaths to enhance tidal volume – All breaths are patient triggered – Used alone or with other modes such as SIMV

Modes of Ventilation SIMV/PS Synchronized Intermittent Mandatory Ventilation

5

– Weaning mode – Allows for combined ventilator timed breaths patient triggered breaths – Pressure support is usually added to spontaneous breaths

Modes of Ventilation Control Modes Volume Control

5

Pressure Control

5

– All breaths are delivered at a preset volume

– All breaths are delivered at a preset amount of pressure. – Used for stiff, non-compliant lungs, i.e. ARDS

– Control modes are not used for weaning. – Breaths that are triggered by the patient are identical to ventilator breaths.

Weaning Indicators – – – – – – –

Resolution of acute phase of disease FIO2 of 40% or less, Peep 5-10 Stable vital signs Stable ABG’s (minimal acidosis) No continuous IV sedation Adequate cough RSBI less than 100

Weaning Indicators RSBI (Rapid Shallow Breathing Index) – Reliable predictor of weaning outcomes – Pt is allowed to breath without vent support for 1 minute, RR is then divided by exhaled tidal volume – Normal value is < 100 – Performed on all vent patients every a.m. in conjunction RN sedation vacation – Not performed on patients in Pressure Control mode

Ventilator Weaning Control mode

Pressure Control Volume Control PRVC

Combined

SIMV/PS

Support mode

Pressure Support/ CPAP

Approaches to Weaning – Spontaneous Breathing Trials – Decreasing levels of Pressure Support – Decreasing SIMV rate

Approaches to Weaning Spontaneous Breathing Trials: he patient is removed from the vent and placed on T-Bar or left attached to the ventilator and placed on Flow-By mode.

he patient’s vitals are monitored during the trial, usually for 30-120mins

Approaches to Weaning Decreasing Levels of Pressure Support: Pressure Support level is slowly decreased over time When the patient has tolerated a pressure support level of 5 -7cm H2O for 2-4 hours, the patient is considered weaned Example order: Wean pressure support by 2 every 6-8 as tolerated. Maintain RSBI < 100. Lowest pressure 5cm H2O. *PS of 5 maintained to overcome airway resistance from breathing tube

Approaches to Weaning Decreasing SIMV rate: The SIMV rate is decreased by 2 breaths/min every 4-6 hours as tolerated When the SIMV rate is down to 4, and is tolerated for 2-4 hours , the patient is then considered for extubation or changing to pressure support mode Example order: Wean IMV rate by 2, every 4-6 hours as tolerated. Maintain RR < 30 w/ no respiratory distress

Passy Muir Valves (PMV) • When is the patient ready? – The patient is alert and attempting to communicate AND/OR – The patient is weaning OR • Usually (at a minimum) to SIMV, if rate is low enough

– The patient has weaned to T-bar and would benefit from the stimulation of hearing their own phonation

PMV • One way valve – Allows air/support in through trach tube – Prevents air/support out through trach tube – Redirects expiration through cords, mouth, nose (upper airway) – Restores positive airway pressure for swallowing – Reduces aspiration – Reduces tracheal secretions – Allows phonation – Reduces vent weaning and decannulation time

PMV Contraindications • • • • • • •

Inflated cuff or fome cuff Unconscious/comatose patients Severely medically unstable patients Airway obstruction/stenosis Unmanageable secretions Severe aspiration risk Severely reduced lung compliance

PMV Placement • Select appropriate valve (Aqua or purple) – We try to fit those who will wean with purple

• • • • •

Suction as needed Deflate cuff fully Suction as needed Try finger occlusion phonation trials Place PMV with or without adaptor with a quarter, clockwise turn – Replace tubing or collar

PMV Trial • Closely monitor patient and vitals – – – – – – –

O2 Sats Respiratory rate Effort of breathing Heart rate Color of patient Signs of distress Negative changes

Reasons for Failure with/Intolerance to PMV • Trach tube is too large • Stenosis, granulation tissue, or vocal fold paralysis • Patient needs more training to relearn phonation with the PMV • Thick and/or copious secretions • Inability to tolerate cuff deflation • Vent requirements/support needs too high for PMV placment

PMV and PT/OT/Nursing • Once a patient has been cleared by SLP to wear the valve without supervision, it should be worn during all waking hours (unless otherwise indicated) • Ask nursing to place the PMV if you are not comfortable doing so yourself • Benefits – – – –

Improves communication Builds confidence Reduces anxiety Facilitates independence and improves locus of control

What if the PMV pops off? • The valve can come off due to hard coughing or the weight of the T-bar • If there are visible secretions, have the patient suctioned or the trach wiped clean before replacing the valve • Reattach the valve using a ¼ clockwise turn. Do Not force it on. • If you are not comfortable ask nursing/SLP to replace the valve • Feel free to arrange cotreatments with speech anytime